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CPS > Acute care > Flashcards

Acute care Flashcards

1
Q

what are side effects of ondansetron?

A 
Diarrhea-self limiting, lasts 48h
drowsiness - rare
extrapyramidal reaction
hallucionation
sz
neuroleptic malignant syndrome
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2
Q

what the mechanism of action of ondansetron?

A

selective serotonin 5-HT3 receptor antagonist!

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3
Q

what are ondansetron doses

A

8-15 kg - 2mg
15-30kg - 4 mg
> 30 kg - 6-8 mg
ORT 15-30 min post

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4
Q

In complicated pneumonias, how often do we have a positive blood culture?

A

10%

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5
Q

What is the Abx choice for complicated pneumonia?

A

Cefotaximeor ceftriaxone +/- Clinda for anaerobic or MRSA

can switch from Clinda to Vanco in culture proven or stongly suspected MRSA pneumonia

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6
Q

How long do complicated pneumonia + effusion require Abx for?

A

3-4 weeks

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7
Q

When do you switch from IV to PO Abx in complicated pneumonia

A

Drainage is complete
clinical improvement
OFF O2

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8
Q

when switching from IV to PO Abx in complicated pneumonia, what Abx d you choose?

A

Amoxiclav

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9
Q

What are surgical options for complicated pneumonia?

A

VATS
Early thoracotomy
Chest tube + fibrinolytics-most cost effective, get out of hospital faster

t-PA at 4 mg in 50 ml of NS for up to 3d

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10
Q

Do you need a repeat CXR post complicated pneumonia+discharge?

A

yes at 2-3 month

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11
Q

why are children more likely to develop intracranial lesions from head trauma

A

larger head to body ratio
thinner cranial bone
less myelinated

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12
Q

what are the most common causes for head trauma in canada?

A 
falls
sports related
direct hit or colliding
Bicycle related
MVA/pedestrian
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13
Q

Clinical features associated with intracranial injury (4)

A

prolonged LOC
confusion
worsening HA
persistent vomiting

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14
Q

How do you classify head trauma based on GCS?

A

14-15 - mild
9-13 -mod
<=8 - severe

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15
Q

Which patients with a GCS of 14-15 require a CT brain?

A

if abnormal mental status or
abnormal neuro exam or
suspect skull fracture

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16
Q

which patients require a skull xray?

A

if LESS than 2 yrs + boggy hematoma

or if concerned about abuse

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17
Q

What is the CATCH rule for minor HI?

A

a child with a minor head injury (witnessed LOC, amnesia disorientation, >1 emesis, irritable) needs a head CT is has >=1:

A) High risk-Nsx: WIGS

  • GCS < 15 at 2 hours
  • suspect open or depressed skull fractures
  • Hx of worsening HA
  • irritability on exam if kid less than 2

B) medium: SDH

  • signs of basal skull#
  • large boggy hematoma if > 2yrs
  • dangerous mechanism
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18
Q

What factors increase the risk of post-traumatic Sz

A 
young age
severe head trauma GCS<8
cerebral edema
subdural hematoma
open or depressed skull fracture
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19
Q

what is the mgnt option for a pt with impact sx or soon after, with normal neuro exam and imaging?

A

can discharge home if all normal

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20
Q

what are indicators of poor prognosis for intracranial injury?

A 
severity at initial presentation
Inc ICP
severity of other injuries
ADHD
SES
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21
Q

who should get a skull xray?

A

if < 2 yrs and boggy hematoma
if depressed skull fracture - CT preferred
if penetrating lesion -CT preferred

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22
Q

What are the 2 absolute indications for head CT

A
  1. focal neuro deficit

2. suspected open or depressed skull fracture or widened or overlaping skull # on xray

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23
Q

what are relative indications for CT not in CATCH rule

A

known coagulation disorder

GCS < 14 at any point

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24
Q

when do we observe pt post minor head trauma

A

if at initial evaluation:

  • severe or persistent HA
  • Repeated vomiting
  • Hx of LOC
  • Amnesia
  • Confusion
  • Lethargy or irritability
  • immediate post traumatic seizure

***need to be observed for 4-6 hours

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25
Q

what is the prevalence of asthma in canada

A

11-16%

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26
Q

What are ED management objectives for Asthma

A
  1. assess severity
  2. Rx to decrease resp distress and improve oxygenation
  3. appropriate disposition pst Rx
  4. arrange proper FU
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27
Q

a sat < 92 % at presentation is associated with what outcome?

A

higher morbidity

greater risk of hospitalization

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28
Q

when should an asthmatic get a CXR

A

suspect pneumothorax
? pneumonia
? FB
if fail to improve with max treatment

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29
Q

when should an asthmatic get a gas done?

A

if no improvement on max therapy

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30
Q

what is the suggested O2 sat in context of asthma?

A

> = 94%

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31
Q

What should be the initial mgnt steps for asthma?

A
  1. treat hypoxemia
  2. give short acting beta 2 agonist - MDI+spacer unless impending resp failure
  3. Steroids
  4. assess response
  5. consider other treatments
32
Q

What are Ventolin SE

A

tachycardia - no known arrhythmia in kids but in adult, need to be on monitor
Low K
Hyperglycemia

33
Q

when should Atrovent be used with caution?

A

kids with soy allergy

34
Q

what is the dose of MgSO4

A

25-50 mg/kg over 20 min (max 2g)

35
Q

what category of drugs id Ipratropium?

A

anticholinergic

36
Q

why is Atrovent useful

A

Used as an add on

  1. reduced hospital admission rates AND
  2. better lung function when used with Ventolin during first hour
37
Q

what can steroids do for asthma

A
  1. reduce need for admission
  2. decrease risk of relapse after initial treatment
  3. earlier DC
38
Q

what can MgSO4 do for astham

A
  1. improves resp function

2. decreases hospital admission

39
Q

when should you use MgSO4?

A

incomplete response during first 1-2 hours in pt with moderate and severe asthma

40
Q

IV salbutamol will help asthma how?

A

improve pulmonary function and gas exchange

41
Q

What are treatment options for children with asthma who failed to improve on continuous salbutamol and IV steroids

A
  1. Aminophylline IV
  2. Heliox
  3. I & V
42
Q

what are the complications of mech ventilation for an asthma patient?

A

26% will have complication

  • pneumothorax
  • impaired venous return
  • cardiovascular collapse from inc intrathoracic pressure
  • death
43
Q

what are reasons to admit an asthmatic

A
  1. need for O2
  2. Deterioration while on steroid
  3. persistent increase WOB
  4. Needing salbutamol more than q4 after 4-8 hours of treatement
44
Q

What are DC criteria from the ED for asthmatics

A

sats > 94% on RA
need ventolin less often than q 4
minimal or no resp effort
improved air entry

45
Q

what is the discharge home plan for an asthmatic

A 
complete 3-5 d PO steroid
ventolin until exacerbation over
asthma action plan
review technique
encourage FU with GP
46
Q

what inhaled steroid can a 3 month old use and a 12 month old?

A

3 month - pulmicort nebs

12 month - flovent

47
Q

at what age can we start ciclesonide

A

Alvesco

6 yrs

48
Q

what is the mortality associated with status epilepticus

A

2.7-8%

49
Q

what acute causes of status epilepticus

A
  1. CNS infection
  2. AED non compliance or withdrawl
  3. AED overdose
  4. Other drug overdose
  5. metabolic disturbances - high/low glucose, low Na, Low Ca, anoxic injury
50
Q

what are remote causes of status epilepticus?

A

cerebral migrational disorders- lissencephaly
cerebral dysgenesis
HIE
progressive neurodegenerative

51
Q

if pt arrives in presumed status, what are important Hx info needed

A
  1. Hx of seizures
  2. associated symptoms - fever…
  3. medications used
  4. Allergies
52
Q

patient in status is found to have BG 2.5, what is the mgnt?

A
  1. IV access
  2. Bolus with:
    5 ml/kg of D10 or 2ml/kg of D25
  3. recheck BG at 3-5 min
  4. if low again - re-bolus
53
Q

what is the Sz termination rate if anticonvulsants are used within 20 min?

A

70-85%

54
Q

if no IV access, what is the first line Rx for seizures

A

Buccal midazolam is better

55
Q

if IV access, what is the first line Rx for Sz

A

IV lorazepam - longer acting and less resp depression compared to diazepam

56
Q

what are second line Rx for seizures

A

IV phosphenytoin and phenytoin

if no IV - IM fosphenytoin or IO phenytoin

57
Q

what are SE of phosphenytoin and phenytoin?

A

arrythmia
bradycardia
low BP

58
Q

what can happen if phenytoin is improperly given - IV interstitial

A

purple glove syndrome: edema, discoloration, pain distal to site

59
Q

when is phenobarbital used?

A

second line
neonatal Sz
pt already on phenytoin maintenance

60
Q

what are SE of phenobarbital?

A

sedation
resp depression
hypotension

61
Q

when would you use pyrodoxine to treat sz

A

if thinking it is a metabolic disorder

may be pyridoxine dep epilepsy

62
Q

what is the MC cause for status

A

prolonged febrile Sz

63
Q

when is status considered refractory?

A

if 2 different drugs used

64
Q

What are the drug options for refractory status?

A 
I&V 
1. continuous midazolam infusion:
fast acting and with short half life
bolus+mainenance
max 24 microg/kg/min
SE: low BP
  1. thiopental:
    can be added to phenytoin only - so may need to stop other stuff
    stay on it for 48 hrs before wean as restart phenobar
  2. propofol/topiramate/levetiracetam
65
Q

if patient with no know allergies, presents to the ED with ? anaphylaxis, What criteria are need to make this Dx

A
  1. acute onset with skin and/or mucosal tiusse and >1:
    - resp compromise
    - reduced BP or other end organ dysfunctions
66
Q

if a pt is exposed to a likely allergen, what features are needed to make the Dx of anaphylaxis?

A

post exposure + >=2:

  • skin/mucosal involvement
  • resp compromise
  • reduced BP or signs of end organ
  • persistent GI symptoms (pain/V)
67
Q

if a patient is know to be severely allergic and presents post exposure, what features are needed to Dx anaphylaxis?

A
  1. Reduced BP
68
Q

what are epi pen doses?

A

Epipen Jr - 0.15 mg for 10 to 25 kg
Epipen - 0.3 mg for >25 kg
Twinject of either dose and provides

69
Q

how do you give epi for anaphylaxis

A

0.01 mg /kg of 1:1000 IM every 5 to 15 min

70
Q

what are second line antihistamines used in anaphylaxis?

A

H1 antagonist - NO effect on resp/GI/Cardio. ONLY for cutaneous symptoms ( Cetirizine PO)

H2 antagonist - in combo works better. Ranitidine PO or IV 1mg/kg

71
Q

What are the steroid choices for anaphylaxis

A

not totally provent to help but used, no effect acutely

  • moderate - PO pred
  • severe - IV methylpred
72
Q

when can the biphasic reaction occur?

A

between 1- 72 hours

most often in first 4-6 hours

73
Q

What is needed for a child to meet Dx of minor head injury

A

need one of these to use CATCH criteria:

  1. definite amnesia
  2. witnessed LOC
  3. witnessed disorientation
  4. persistent vomiting
  5. if less than 2 - irritable
74
Q

how does epi effect a, B1/B2

A

alpha 1 - A for arteries
B1 - one heart
B2 - 2 lungs

75
Q

why is fosphenytoin better?

A

less resp depression
runs faster over 5 min
can be run in with D5 and therefore don’t need IV
less risk of purple glove

76
Q

who should receive ondansetron?

A

mild to mod dehydration
6 mo to 12 yrs
who failed oral rehydration

CPS (10 decks)

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